Final Verdict on TRT Effectiveness

BBC Sounds, Music, Radio Podcasts Hi, I'm Xing Singh, and I'm Simon Jack, and together we host Good Bad Billionaire, the podcast exploring how some of the world's richest people made their fortunes . And we're back for a new season with a brand new lineup of billionaires. Yeah, global pop icon Beyonce. Hollywood movie director Steven Spielberg. Football superstar Christiana Renalo, anyone? And as ever, we're asking you to decide whether they're good, bad or just another billionaire. That's good, bad, billionaire. Listen first on BBC Sounds. Hello, I'm Greg Foot and welcome to Slice Bread, the show that investigates the Wonder Products promising to make you happier, healthier, or greener. Each episode, we follow the crumbs of evidence to find out if one of your suggested Wonder Products is indeed the best thing since Sliced Bread or Marketing the S . And today's suggestion comes from Clive King from Kent. Welcome to the studio Clive. Thank you. Tell us then, what is the Wonder Product you'd like us to investigate today and why? So I'd like you to investigate TRT, testosterone replacement therapy because I was feeling a little bit low about this time last year and I just wondered if it maybe was my age now that I'm in my fifties or whether it was something else and there was a company that suggested I might have low testosterone . So I sent off for a blood test, got some results back and then they asked me to do some further tests, more expense . So that's when I thought I'd reach out to you guys to find out would it be a good idea? Would it be sliced bread? The company that you used was Manual. Manual. Yes, I've seen them on my social media. I should say that we're recording this at the end of twenty twenty five. Manual's currently going through a rebrand to become Voi. Now, we will likely use Manual throughout this record, but when you listen to this, they may well be called Voy. Okay . So was it general low mood? Was it also low energy? Was it related to sport? Low energy more than anything else. Yeah, I always have a reasonable amount of energy for sport. And what led you to turn to one of the digital health companies to check this out? Did you think about going to your GP I did think about going to the GP but I don't like to take up the dosctor' time unless it's something seriously important so I thought I'd just have a little check to see if there was something I could do myself . Yeah, my social media is constantly telling me that as a forty two year old guy I should, get a testosterone test. Most of the videos appear to be from fitness influencers. Tell me about what the testing process looked like then. What did you have to do? I did a fingerprick blood test into a small vial and then send it off for the test, so nothing more technical than that really. Well, there are more and more of these home testing kits popping up offering to test everything from your cholesterol levels to diabetes risk, markers of your liver, your kidney, your thyroid health , there's a long menu of options. As you've noticed though, Clive, the trend appears to be testosterone tests, and we've seen more and more emails come into our inbox asking us to investigate these. On that, thank you to anyone listening who has sent over a wonder product suggestion to sliced dot bread at bbc. co ck them coming. We're going to get into all this to discuss TRT so taking testosterone. We are joined by the president of the British Society for Sexual Medicine, the BSM, an author of their gu idelines on testosterone deficiency, Professor Mike Kirby. Hello, Mike. Hello, Greg. So the first question has to be, what is testosterone, Mike? Well, it's a sex hormone in both men and women actually. And it's necessary for boys to develop at puberty their sexual characteristics. So the testies start to produce it when boys get to about ten or eleven and they start to develop all those things that show they're developing into manhood . When people hear testosterone, I think they often think about it in the context of driving you to go to the gym and pump iron or having a high sex drive, perhaps increased aggression as well. What does testosterone directly impact? In practice every organ in our body. It's essential for the functioning of the brain , for muscle development, for keeping the cardiovascular system healthy . That's important for liver function . So it's not just for sexual development, it's an essential hormone to keep us healthy. I think this story that testosterone makes you aggressive is simply not true. It's a story on that we all have and at normal levels, it keeps us healthy . So Clive, you mentioned that when you turned fifty, you wondered whether the lower mood, the low energy that you had, was age related or testosterone related . Mike, do men see their testosterone drop in middle age, like women see with estrogen . Well, the European male aging study did show that testosterone drops just over one percent per year as we get older. But that being said, if men stay healthy , seventy five percent of men will keep normal testosterone levels until our age. It's quite different from women because women lose production of estrogen from their ovaries at the menopause and then don't make anymore, whereas men carry on making testosterone right through their lives as long as they stay healthy. So it sounds like there isn't a strong parallel then to the menopause. No . I think we need to define what we're talking about . And we are talking about hypog omedism. That's the medical term. And hypogomedism is when the levels of testosterone drop below the normal range . And the British Society for Sexual Medicine defines normal range as twelve to thirty and anything below that requires further investigation. So what do you think of Manuel's line? I've seen this repeated elsewhere as well, that one in four men suffer from low testosterone? It's difficult to know, actually . There have been some studies. The Massachusetts Male Ageing study suggests it's somewhere between six and twelve percent rather than twenty five percent , but it's certainly under diagnosed and definitely undertreated. And what symptoms do you get if you do have testosterone levels? Sub twelve . Sexual symptoms are the most common lack of desire , lack of mourning erections , difficulty getting and maintaining an erection , difficulty with orgasm. And then there's depression and tiredness , loss of muscle, lack of motivation . All these things are quite common in men in middle age. Well, let's get to your results Clive and compare them to these reference ranges that we've just heard from Mike there. So you've kind of volunteered to share your results with us. What did they measure your testosterone level as so mine came back as ten point seven. ten point seven, right? So we've just heard, Mike. You said that the normal level is twelve to thirty. So that sounds like that would indeed be low. That is indeed low and we would want to do further tests to try and clarify exactly what's going on. Which is exactly Clive what Manuel suggested would be the next step. Yeah, so is that something that I would go to my GP for? Or would I get a positive reaction from the GP if I said I believe my testosterone levels are low? I sincerely hope that you would get a positive response from your GP because it is something that GPs can deal with. We do spend a lot of time educating GPs about how to investigate men with a low testosterone and how to manage it. Have to be fair to GPs , they get well over two hundred guidelines a year , which means that many GPs may be a bit unfamiliar, but actually it's no different from prescribing hormones for women at the menopause . It's a similar theory that we are wanting to replace the hormone that is not there in sufficient quantities in the same way we replace estrogen for women when they become estrogen deficient . Clive, you were also given a second figure from Manuel. Your free testosterone level. What did they give you? So they gave me a zero point two five. So Mike, what is free testosterone compared to just testosterone. Well, free testosterone is the active testosterone that whizzers around your body doing all those important things in those various tissues that I mentioned. In fact, only two percent of testosterone is free . Reading your results here, manual say quote, typically men who have low free testosterone experience symptoms like low energy pulsep, etc. So is it more like someone's free testosterone levels that 's key here rather than their overall testosterone levels . Yes . And do you have reference ranges again for the free testosterone level? It's free testosterone. The lower range is zero point two five . So that would actually put Clive right on that lower range . It is just at the lower end of normal and I'd want to examine him to see if I could find any cause for f usree to testosterone to be at the lower end . If you've had mumps or some form of inflammation of the testes or you've got undescended testes , then that can cause a low testosterone and like to know what his waste measurement is . Obesity, particularly abdominal fat is a major cause of a low testosterone . So there are things we would want to be looking for . So Clive, it sounds like it's not just about the figures from the blood test. They have to be taken in tandem with other symptoms and other possible causes . What we're hearing here is that to acc assuressately what's going on, we can't just rely on this fingerprint test, right? This is something that Manuel do recognized. They said to you, next step for you is to get an enhanced test. So we thought it'd be good to invite them on to comment on this. So I'm going to bring in the director of Men's health at Manuel and an NHSGP who sits on the committee of the British Society for Sexual Medicine alongside Mike, Dr. Jeff Foster. Welcome, Jeff. Hi, thanks for having me. So Jeff, you've heard Mike talk about how he's testosterone deficiency should be diagnosed. Talk me through the steps that Manual are taking. So we mimic the BSSM guidance pretty religiously really. So you have your first blood test and then once you get your results back usually about forty eight hours or so, you'll then be invited to have a second test if it shows that your tests are potentially low or need further investigation. And the second test is a more in depth test that looks for causes around why you might have low testosterone, because we don't want to give testosterone to somebody that might have a different cause for their low tea. For example, if it was thyroid disease or anemia or kidney problems or something else. And we also want to check that it wasn't a one off because the other thing is you should never trust one lab result to say that's the reason why you got low testosterone. So we repeat it again . And then the third reason is to make sure that if you were considered for any form of treatment, you're safe to have it because we want to make sure that your liver is okay and that your prostate is fine, etc , etc. So it is a slightly more laborious process, but we want to do it to make sure you're safe. And if those results come back again and something comes up in those that are as abnormal, well then we offer you a consultation with one of our doctors, all of which are men's health and testosterone trained and we run through why we think your results are low or what treatment options you might want to have. And just to put some costs to this, Jeff, the at home fingerprint testosterone test is currently around thirty four pounds. The enhanced testosterone test is around fifty for the test kit only, eighty for the test kit and a clinic appointment and one hundred and twenty for a test kit and at home nurse visit . Then to speak to a specialist doctor it's around eighty pounds and then you start your treatment. And when I asked Clive earlier why he didn't go to the GP, you said Clive, you didn't want to take up the doctor's time . Is this why many people are turning to manual and other at home tests? I'm a bit like Mike, and I don't think we should be disparaging general practice or saying that it's because of NHS availability. But this is a growing area of medicine. And before it's taken up by the NHS and before it becomes well established, there is a gap. And people are becoming more aware of this. And because they're more aware of it, but the NHS doesn't offer it, then you will have to go private to do that. We often hear it said that men are bad at going to the doctors. Do you agree with that, Mike? Yes, I do. Certainly there have been studies which show that men diagnosed with hy pogonetism have probably had the symptoms for at least four years before they get diagnosed. Jeff, I'm interested in the ranges that we heard earlier from Mike. So Mike said that the BSSM consider a testosterone measurement under twelve to be low, eight to twelve to require further investigation, under eight to require treatment. Does Manual use that same twelve as a cutoff? Like say someone measured thirteen , would that be considered quote normal . So firstly, you've got to remember that every individual testosterone test will vary. And that's why you should never go just by what the blood test says . But if somebody is twelve point five and they have these symptoms, I'm not going to say well you can't have treatment. The other thing is that there is evidence from something called the T four DM study which showed that if you look at taty diabetic men, they could often respond well to treatments if their levels are up to nearly fifteen nanomals per litre. So it does actually beg the question what do we do for those patients that are in that middle group so twelve to fifteen? You have to be realistic in medicine that a cutoff is not a hard cutoff. Okay, so if Clive decided to do the enhanced blood test and then have the consult ation , if it was deemed that TRT could be useful for you, Clive and he opted for it, what Demanuel offer? The discussion would be can we find a reason why your testosterone is low? If you are somebody that's maybe more overweight is your underlying cause than your testosterone we've started adding some of the new weight loss medications and we might find that that's actually a better treatment for you than testosterone . We might offer you a pure testosterone treatment if we can't find a cause for this and it appears that it is an age related condition and that could be an injection or it could be a gel and we have tablet versions for younger people that might want to consider maintaining their fertility . So there isn't really a one treatment that fits every guy. And I think if you ever go to a clinic where only one treatment is offered, then you probably won't be walking away. So just to put some figures on what you mentioned there, the injections look like they cost anything from ninety nine to one hundred fifty nine pounds . That's monthly, isn't it, Jeff? Yeah, yeah. The gel is one hundred and twenty nine to one hundred and fifty nine pounds or also tablets ninety nine pounds a month . So this is a significant cost, isn't it, Clove? Absolutely. So the injections look to be the most popular. Your website says ninety eight percent of men choose injections. Tell us how you suggest that they're taken . There are various different ways you can use injections, and the long acting injections can go up to twelve weeks at a time and they're more commonly used within the NHS. I haven't found as great a success with those largely because the time it takes to get feedback from your patients is much longer. We also find that you can get higher side effect risks with the longer acting ones compared with the short act ing ones, which you can inject maybe once or twice a week and you can use a tiny little insulin needle and you can do it subcutaneously into either your fat or your you can do it as a tiny little intramuscular one to your thigh or your bum. I think it does sound quite daunting, but because the success rate of the injections has been so good, it's largely been patient driven and they opt for this as their preference of treatment. Jeff, can I ask what the side effects are? Yeah, definitely. So the most common ones we see in patients actually are that in the first couple of months you might find if your level was very low and it suddenly gets returned to normal, you could get some acne or some spots coming up and it's a bit like going through a kind of second puberty. But as your levels settle out again, those acne levels go back to normal. You might find that you get a little bit of puffiness around the ankles and you've got the same risks you can have with your breast tissue. Some guys complain that they can get nipple tennis when they first start. And that's due to the estrogen level starting to come up. And we have to remember that testosterone converts to estrogen and you want estrogen as a guy and you just don't want too much of it. But these are very rare side effects, you know, talking less than five to ten percent max . The big worries that patients have around testosterone are not the sort of transient side effects. It's more the worries about is this safe? Like can I take this drug and is it going to cause me to have prostate cancer or is it going to have heart attack at risk? And I think testosterone's always been really poorly associated with adverse health outcomes like that. When you read the list, that makes you feel concerned, but those risks are actually based on some rather old studies . So we've got two recent studies which have been very reassuring in terms of risk of heart disease and risk of prostate cancers, the traverse study, which was done in five thousand two hundred men using testosterone . And in fact, there was no extra cardiovascular risk or prostate risk with those. And there was a very large study on the state forty one thousand seven hundred men older than sixty five. And testosterone replacement therapy didn't appear to increase any of those risks . And in fact, there was an inverse relation so that the men treated with testosterone actually were getting less cardiovascular problems than the men who weren't. I was going to ask that question whether there was a link to testosterone levels to the rate of mortality . There is actually because if you have a low testosterone and it doesn't get treated then that increases your risk of mortality . So if you have a low testosterone then you will have only cardiovascular risk factors within you. In other words, you will tend to have a high blood sugar, a high cholesterol. That increases the risk of heart disease and strokes . Well, that's go back to the injections. How effective are testosterone injections, Jeff? They've been proven to be the most effective for our patients. And this is because once you do an injection, it takes two minutes or so and then they can forget about it. The gels are good , but you have to apply it every day. You have to give it time to absorb into the skin. If you have skin problems or maybe more hairy or something, you may not be able to absorb it properly, and then you get variations. I was reading about the topical gels , there's a warning about transferance, particularly to children and to women where the testosterone gel or lotion can apparently affect the menstrual cycle. And Manual say that quote you should shower before any physical contact with others to avoid testosterone exposure risks. These are actually really, really rare complications. When it comes to transferrance risk, transfer is actually extremely low, but you need to be open about it . And if you were to put a gel on it and then you were just lucky enough to have some intimate time with your loved one, then yes, there is a small chance you could rub that onto the person next to you. But generally we just say, you know what? Just wash your hands afterwards. Mike, what do you think about the effectiveness of gels? I think they work very well. Okay. So the final option then is the testosterone tablet. And Jeff, you mentioned earlier that tablets can be useful. You said to maintain fertility. Tell us about that . So you can use other medicines that stimulate your testoster one to be produced from your testicles. They're very good in younger patients who maybe have a different cause for their testosterone to be low. And the advantage of that is it also reduces the problems of fertility because you're not shutting anything down. The problem is of course that only works for that subgroup of patients where you know what the cause is and it's related to that. So older guise often doesn't work and it'll only work in that specific group where we need to tell your testicles to work better. So Clive's, which of those types would you think you would go for and why? The prospect of just taking a tablet and then getting on with my day sounds right at the top of the list. The gels also sound like quite a nice convenient alternative as well. Next after that would be the injections . So let's talk about what other effects TRT can have. Jeff, we saw a manual say it can help with enlarging muscles, improving sleep and even memory. So let's take those one by one. Let's start with muscles. You know, we like to dig into the studies here on sliced bread. So on the manual website, you write, studies show that increasing testosterone levels stimulate muscle protein synthesis and enhances muscle mass. There was a link to a study. We looked at the study. They looked like it only used five people. Yeah, and to be fair, we have got better studies that have come forward. I think some of the newer studies we've got are showing that you actually get significant improvements, but not just in muscle size, but we're also looking at metabolic conditions. So reductions in things like blood glucose risk and reductions in cholesterol levels and improvement in blood pressures and cardiovascular risk, etc . Mike, do you feel the evidence is there for the impact of taking testosterone TRT on muscle function? Muscle strength? I do, yes, I do. I mean, we see it in the men who have their testosterone taken away as a treatment for their prostate cancer and their muscles just waste away. We lose muscles as we age anyway, but it's made much worse if we have low testosterone and testosterone replacement will stop the deterioration and if you do resistance exercise that will stimulate the muscles to come back. So it takes work, clive. As we know, in life it's very easy to become unhealthy far more difficult to become hard healthy again. Yeah . Am I right, Jeff, that taking these TRT products would actually be classified by the World Anti Doping Agency as a banned substance ? Yeah. If you are somebody that's competing in professional sports that has drug monitoring, then you would have to declare that if you were taking testosterone replacement therapy. Even for tiddly wings . If it's competitive tiddly wings, then perhaps would you have any qualms though with that Clive of taking something that is, you know, a banned substance by the World Anti Doping Agency? I can understand the reasoning behind wanting everybody to be on a level playing field when it comes to elite sports and even in the amateur game , my youngest is a semi professional rugby player and I would be very concerned if he was taking any supplements that were banned . Well, that's a good point because you see a lot of stuff online about young adults taking testosterone that they're eighteen, they're twenty, and they're looking to enhance their physique in the gym. Jeff, they haven't gone through the consultation process that you've clearly outlined. So this is a concern, right? Yeah, it's an absolute nightmare. So I don't want to see anyone in our clinic at least under the age of thirty unless I know for sure why your testosterone is low. The vast majority of men in their late teens and early twenties are still producing and still increasing their own testosterone. And the last thing you want to do is start giving them testosterone. It's a real problem in the younger men because it switches off lutherizing hormones which stimulates the cells and the testes to produce testosterone. So these young men taking testosterone, they build up their muscles, they think I'm great. They then stop it and they feel awful because the the lute and vestic hormone may be suppressed for months . And it's a real problem because we don't want to get them testosterone because it makes them infertile. Well, now that is really worth reiterating that if you are planning on starting a family , you should not be taking testosterone. Let's move on to sleep. On the manual website you write Say good night to insomnia and look forward to sleeping soundly so what's the evidence for the effect of TRT on sleep . Yeah, there are actually some good trials showing testosterone relating to sleep in particular low testosterone affecting sleep. So there's a nice trial done in two thousand seven that looked in older men, age sixty five and over it shows that you' ifve got lower testosterone , these guys do have disturbed sleep and your sleep quality is poorer. And I guess a really good analogy with this is menopause in women. So we think that if your testosterone is low, obviously you're not going to produce as much estrogen because guys con tveresttost erone to estrogen. And estrogen is quite often the thing that gives you your better sleep quality or is the thing that often disturbs sleep during female menopause. If you suddenly take those hormones away, testosterone and estrogen, it's going to make your sleep worse. You can put those back to normal and patients will often find that sleep starts to improve. Right. Mike, you on board with this potential TRT benefits for sleep? Yes, indeed. I'm on board with that, I think it does help names sleep. But what about memory? Because again, the manual website says quote, testosterone can help you feel sharper and boost your memory. Now there are a couple of studies that show that spatial memory is improved with testoster , but also there's a difference between concentration memory and risk of dementia. So we now think that testosterone could, and I can only say could have a reduction in possible risk with dementia over time. But we can't prove this yet because we haven't got enough years to say this is definitely a risk. I mean, one of the biggest complaints of men who are hypercanadal is brain fog . And we know that hypergenadal men do have a higher incidence of dementia . So yeah, I think it's an issue and testosterone replacement therapy will reduce the risk of both brain fog and future dementia. Jeff, we saw Manual claim that nine in ten patients see life changing results after just three months on treatment. That means you need to take it for at least three months and also how long do they then need to take it for? As per BSSM guidance, I'd recommend that patients take it for at least six months, and that's because you will notice symptomatic improvement usually in a couple of weeks. Often patients start to feel just like they've got a bit more energy and that they can feel more motivated, their sexual function gets better. And all those symptomatic things are brilliant and then they kind of level off about ten to twelve weeks. And it's not like you lose all those gains. It's just that maybe your body's kind of saying all right,, that's my new normal. But that's when you start to see the metabolic changes over the next three to six months after. And that's why we want to keep you going because if I am going to give you a medicine that's going to make your bones more dense, it's going to increase your muscle mass or decrease your risk of things like cardiovascular disease, whatever. That's going to take time. And that's why we want to give you six months to see actually are you really benefiting from this medicine or not? And Mike, if it's working, do you then need to keep on it to keep having those effects? Yes, you do , because when you're on testosterone it actually switches off the luteinizing hormone from your pituitary, which stimulates the cells and the testes to produce testosterone . So if you suddenly stop it then you're actually worse off because you've suppressed your leutaminizing hormone from the paturatory. So yes, you do need to stay on it life long once you've started if you're a truly African adult. Yes, it's all in. It's all in, yeah, and significant cost a month for a number of years . Yeah. It can be prescribed on the NHS but you see your GP and ask for a test osterone implant test, it's perfectly possible to get all the necessary investigations done and be prescribed the right treatment. And you do need careful follow up. It's not just the cost of the drugs, it's the cost of ongoing care. And just to wrap up this section on taking testosterone directly, I want to talk about women taking it. So Kate Winslet, Halle Berry, there are a number of celebrities who are trumpeting the benefits of TRT. Mike, do women need testosterone? The simple answer is yes, they do need testosterone . They have about a tenth of the testosterone that men have, but small amounts of testosterone are very important , particularly for sexual desire . So yes, it's a good treatment for women when used appropriately. We do mention testosterone in our previous slicebread episode on menopause supplements when we talk about the different types of hormones that wom en can take as part of HRT as part of hormone replacement therapy. Definitely go have a listen to that over on BBC Sounds. Okay, and on to the SBBS question about TRT then testosterone replacement therapy, Jeff, let's start with you on this. I mean, as director of men's health at Manual, Soon to Be Voy, I feel like I know what's coming here, but TRT, SB or BS B. I mean, if you have somebody who genuinely has low testosterone , if you give them testosterone replacement therapy, it is a life changing drug. So it's not the thing for every man and I do not want every man having testosterone replacement therapy, but you find the right patient and you give them the right treatment and they'll be eternally grateful. And Mike, what about yourself? Is testosterone replacement therapy SB or BS? In hypergenadal men, it's definitely SB. And we've talked about going to your GP as a route for this. So what do you feel about the offerings of the likes of Manual or other try at home tests or ASB or BS? Well, I rather agree that it's filling a gap in the NHS at the moment because men find it so difficult to access services in the NHS at the moment , they're just not going . And I think if they're not going and they're hypergeneral, they're putting themselves at risk. They have a choice. Clive, where does this leave you? Are you going to go ahead and get those extra tests and potentially take TRT? As I came in here, I was uncomfortable about investing what could potentially be a large amount of money into something that perhaps wasn't going to benefit me at all. Both our experts here and Mike and Jeff have convinced me that it would be a good route to go down, but I think rather than going straight in from the private point of view, I've got to push for my GP to see if they can do something about it. If not, if I come across a brick wall, then I'll have to go down the route of going with Manual or similar companies. Was it helpful? Very great stuff. Right. Cheers, clavic. Well thanks for coming. Thanks for sharing all that as well. Thank you. Appreciate it. Well with that, I shall wrap up this episode of Sliced Bread. A big thank you to Clive, Mike, and Jeff for joining me. And if you're listening to this and you're thinking, Greg, I have a wonder product I would really like you to investigate, please do send it over either on email to sliced. bread at bbcot or as a message or a voicemail on WhatsApp to zero seven five three three six eight seven Next time we'll be covering Kafir, one of the latest food fads. It comes as a drink or a yogurt and contains lots of living microbes that are supposed to be good for your gut. But can it deli ver on its health promises? I'll be finding out. See ya This episode of Sliced Bread was researched by Phil Sansom and produced by Simon Hoban and me, Greg Foot. Our studio manager was Kelly Young, and Slice Bread is an audio north production for BBC Radio four. I'm Dr. Chris Van Tillichen and I'm Dr. Zand van Taliken. Chris it's that time of year when we set resolutions. It certainly is done, and that is why in January, our four episodes of WhatsApp Docs are going to be on the key themes that feature in resolutions alcohol, food, exercise, and the whole notion of resolutions themselves